Tinnitus Treatment in a VA Setting

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Amie Lester
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1 Tinnitus Treatment in a VA Setting 2006 AVAA Meeting Judy Abrahamson, MA, FAAA Central TX Veterans Health Care System

2 Tinnitus Treatment at CTVHCS March 2003 Training at Emory March 2003 Staff In-Service April 2003 Began Treatment June 2003 Training from J. Henry July 2004 Added Second Audiologist March 2006 Change in treatment model

3 Tinnitus Retraining Therapy Components Informational Counseling Sound Therapy Devices Environmental enrichment Hyperacusis Protocol

4 Treatment for TRT categories (all with sound enrichment & counseling) 0 Abbreviated Counseling I II III IV Sound generators mixing point Hearing aid or combination unit SG set above threshold or combo unit SG set at threshold, very slow increase

5 Patient Referrals 10 Audiologists from 3 sites referred to 2 Tinnitus Specialists 133 Referrals 111 Patients Seen Tinnitus Impact Screening Questionnaire & clinical judgment were used to determine need for referral.

6 Original Treatment Model Tinnitus Retraining Therapy 30 min interview / overview to determine candidacy 90 min evaluation & educational counseling 30 min to issue bedside sound generator Discharge if category 0 60 min device fitting 30 min follow 4-6 weeks for device 30 min follow 3 month intervals Repeat THI at 6 month intervals

7 TRT Evaluation Tinnitus Handicap Inventory Tinnitus/Hyperacusis Interview Loudness and pitch matching,. UCL measures

8 Revisions to Treatment Model First (after 3-4 months) Omit 30 minute interview as unneeded Second Revision (after months) Abbreviated counseling and no assessment for category 0.

9 Hearing Aids 3 Previous Users 7 New Fittings 10 Declined 2 RFC 7 Not recommended Combination Units 2 Previous Users 13 New Fittings 3 RFC Maskers 2 Previous User Devices (Based on 111 patients) ITE Sound Generator (SG) 7 New Fitting Bedside Sound Generator 3 Previous Users 74 New Issues 5 No benefit for sleep (9.7%) 5 Rejected / returned 6 Declined 4 Self Purchased 33 Creative solutions

10 Compounding Issues 27 PTSD 16 Depression 8 Substance Abuse 7 Sleep Disorder 5 Anxiety 5 Neurosis 5 Migraine 3 Meniere s 2 Tulio s 2 Closed Head 2 Bi Polar 2 Panic Attacks 2 Alzheimer s 1 Auditory Hallucinations 1 TMJ

11 Professional Contact Total Contact Hours Total # of Visits hours 225 hours 35 hours 22 hours Total 430 hours 425

12 Missed Opportunities (Based on 111 patients, seen for 425 visits) No Show 17 Initial Visit 21 Follow-up visits Cancellations by patient 5 Initial Visit 9 Later Visits Cancellations by clinic 2 Visit Not Needed 2 Other

13 Patients New Patients Discharged Patients Total

14 Patient Treatment Length of Treatment (66 discharged pts.) Average # of Visits (all 111 patients) months months months month

15 Patient Treatment (cont.) (Based on 111 patients) Avg. Total Contact Time Per Patient Average Length of Visit minutes 255 minutes 143 minutes 161 minutes 59 minutes 65 minutes 47 minutes 68 minutes

16 Complexity of Treatment (Based on 111 patients) 27 Counseling only 39 Counseling # Bedside SG 30 TRT 9 With ITE SG/Combo 21 With aids 8 Hyperacusis 8 Hyperacusis or Tinnitus? 2 Masking 6 Change from TRT to Masking

17 Miscellaneous (Based on 111 patients) 13 Declined Treatment 2 Intermittent Tinnitus 4 Female Vets 2 Inappropriate Referrals 1 Cure (Acoustic Neuroma Surgery) 2 Inappropriate Behavior 6 Compensation Issues 10 Normal Hearing

18 Positive Outcomes (Based on 29 patients with complete data sets) 92% reported better sleep 62% showed 20% or greater improvement on THI

19 Positive Outcomes Based on 29 patients with complete data 82% showed a 20% or greater reduction in % of time aware of tinnitus 79% showed a 20% or greater reduction in % of time bothered

20 Positive Outcomes Based on 29 patients with complete data 52% showed reduction of 2 or more points on 0-10 scale 52% reduction in annoyance 46% reduction in effect on life

21 Problems PTSD or Hyperacusis? Knowing when to discharge for lack of progress Poor compliance with protocol Compensation issues Patients lost to follow-up Coordinating with colleagues Inefficient delivery model

22 Based on: New Model Tinnitus Management Model used Cleveland Clinic (Newman & Sandridge, 2005 AAA) Audiologic Tinnitus Management, James Henry, NCRAR

23 New Model Tinnitus Management Tinnitus class is initial treatment option for all. Informational counseling Basic management skills Treatment options Hearing protection Self-referral for additional treatment if needed

24 Case Studies (see separate handout) Best Patients Worst Patients Confusing Patients Average Patients

25 Conclusions 55% needed minimal treatment (SG and/or brief counseling) that could be done by staff with minimal training. Therefore, model is being changed to class enrollment. Veterans may request additional treatment if needed.

26 Conclusions Bedside sound generators provided significant benefit. Trial should be offered to all tinnitus patients. Case Load was manageable. 10% of the TRT Specialists total case load and 1.3% of total clinic audiology visits for first 3 years.

27 Conclusions Tinnitus treatment provides significant benefit to veterans. It is an important and feasible addition to a VA Audiology Clinic.

28 References Henry, JA, Clinical Management of Veterans with Tinnitus. NCRAR. Newman et al, (1996). Devel. Of the THI. Arch Otolaryngol Head Neck Surg 122: Henry, JA, et al, (2002). Assessment of patients for treatment with TRT. JAAA13:

Preface. system has put emphasis on neuroscience, both in studies and in the treatment of tinnitus.

Preface. system has put emphasis on neuroscience, both in studies and in the treatment of tinnitus. Tinnitus (ringing in the ears) has many forms, and the severity of tinnitus ranges widely from being a slight nuisance to affecting a person s daily life. How loud the tinnitus is perceived does not directly